The Uses of a Hospital: - By an Hon. Surgeon
FIRST:- To relieve and treat the sick and necessitous poor.
SECOND:- For the training of Nurses.
THIRD:- For the training of Students.
FOURTH:- For the Training and experience of Specialists.
(Sydney Hospital 1918-1919, p.15)
Introduction
Hospitals and hospital-like institutions have had a place in European society for over 2000 years. From being expressions of Christian charity or non-denominational philanthropy to a means of purchasing spiritual rewards or worldly reputation, from refuges for society's outcasts to gateways to death to places of spiritual, moral or physical healing, the perceived function of hospitals is not always consistent or easy to define. This essay will examine various perceptions of the function of hospitals throughout their history and why certain groups came to hold these views, the historical perceptions of hospitals contrasted with modern perceptions. These perceived functions include charity, imprisonment and religious work. A person's class and relationship to a hospital were often the deciding element in how he or she perceived its role in the community and the functions it performed, especially with such larger institutions such as the General Hospital of Paris. The perception that “hospitals make you sick” dates from the medicalisation of hospitals and still exists today, coloured by a a host of other perceptions about the medical profession, public institutions, community health and the consumers' “right to know”.
“Hospitals make you sick”
Hospitals have borne the blame for disease and death since at least the end of the 18th century. The military surgeon Dr Robert Hamilton said in 1787 that “among the causes of sickness and death in the Army are the hospitals themselves” (ed. Poynter, 1964, p.161). Late 18th century hospitals were widely seen, especially by those who were likely to be patients, as “gateways to death”. One observer of the Hôtel Dieu in Paris described the plight of the patients in no uncertain terms: “ these poor wretches come out with diseases they did not have when they went in, and often pass them on to the people they go back to live with” (Diderot in Sand, 1952, p.86-87). Even the Hôtel Dieu staff cannot have thought much of their patient's chances of survival – the hospital charts before the reform had a space for entering the date of death but nowhere to enter the date of recovery (Richmond, 1961). In light of this it seems no wonder the poor people of the time thought of hospitals as a conspiracy to kill them (McKay et al., 1984). The perception that hospitals are detrimental to patients' health continued through the 19th century. According to Granshaw (1994) 19th century Sanitarians were horrified at the death rates of urban hospitals and saw them as inappropriate places to treat the sick, vastly inferior to country hospitals. Our modern perception of hospitals is coloured with all the scepticism, reservation and insecurity we have about all facets of medicine. The public demands transparency and accountability and no longer accepts anything less than the highest standards of professionalism. In a disturbing parallel of Diderot's time, the short time of most patients admitted to hospital spend in-house today means that where an infection is contracted from the hospital, it only becomes obvious after the patient's return home (Ayliffe et al., 1999). Although this hasn't seemed to impact on the public's perception of “preventable” hospital illness and death, which is assumed to occur within hospital walls, the perception is that hospitals should be places of perfect conduct and expertise, but unfortunately are not, and this must be changed. This attitude is succinctly summed up in the words of Helen Hopkins of the Consumer's Health Forum of Australia: “If mortalities are occurring we need to have systems to ensure they don't recur” (Brown, 6 June 2005, p.6).
However, not everyone has held such a dim view of hospitals. Over the ages founders, patrons and subscribers of hospitals have all seen them as beneficial institutions, either for their own personal health or benefit. One of the encouragements to support an 18th century voluntary hospital for those who could afford it was not just the increased standing it bought in the community, but that it would prevent sick beggars roaming from door to door spreading disease (Cartwright, 1977). Similarly, sick servants could be send to hospital rather than endangering the health of the family (ed. Poynter, 1964). For the wealthy of the time, then, hospitals were seen to act as a sort of protection from disease. Before the 15th century, hospital founders and their descendants found that a convenient function of the hospital was accommodating their household if they required it when travelling (Cartwright, 1977). Obviously they couldn't have thought the risk of contracting anything was too great, but of course care of the sick was not the the only function of hospitals at this time – they also offered lodgings to pilgrims, the homeless and the elderly.
The hospital as a charity
The most widespread and usual perception of hospitals, the function that only disappeared when hospitals became the pinnacle of medical technology, was that of a charity. The Christian compassion for the poor and afflicted expressed itself in the form of hospice or hospital, in lazar houses for lepers and in movements like the Hospitallers and later the Catholic Vincentians and Daughters of Charity. Only in recent times has effective healing had a place in hospitals or was expected to. Today we look back on these institutions as fulfilling the roles of aged-care homes, orphanages, homeless shelters or combinations of all these things (Cartwright, 1977). The function of these institutions was not so much healing as caring, providing compassion and practical assistance in the form of shelter, clothing and meals. Oddly enough, while we think of our modern hospitals as being purely places of serious medical practice, Barnes (1961) mentions that hospitals are sometimes seen by marginalised groups, such as unemployed migrants, as a more practical form of welfare, providing meals and accommodation as well as treatment for illness.
The voluntary hospitals of the 18th century were, as the banker Henry Hoare put it, the product of a revival of “the True Christian Spirit of Justice and Charity” (in Cartwright, 1977, p.36). Although extremely selective when admitting patients, the charity function of these hospitals extended beyond the “deserving poor” person actually admitted into the hospital but also to their family, who weren't forced to abandon their jobs or strained to care for and feed the invalid (Risse, 1994). Although these hospitals, founded by the philanthropic and upwardly mobile affluent classes, were primarily for the medical care of the working class, other subscription hospitals had a less medical function. The hospital established by the Royal Navy at Greenwich in 1694 functioned as a pension home for aged or disabled seamen, and sailors paid a monthly contribution in return for the privilege of retiring there (ed. Poynter, 1964).
Another product of the philanthropic revival was the establishment of foundling hospitals. Charles West, the founder of such a hospital, envisaged it as a place where poor sick children were cared for and where mothers whose children were unable to be admitted received instruction on how to care for them (ed. Poynter, 1964). Unfortunately, despite the charitable intentions of the founders and supporters, the reality of these institutions was that they became a place to dump unwanted children. The hospitals weren't just used by the mothers of the poor working class who couldn't afford to feed another child, but also by overburdened parish officials who would send their foundlings to the hospital rather than care for them within the parish (McKay et al., 1984).
The General Hospital of Paris was the expression of the authorities' interest in the welfare of the homeless and poor who relied on alms for survival. To the authorities and those members of the public unlikely to ever find themselves inside the hospital it was seen as an excellent, efficient means of dispensing charity to more poor people at a lower cost. The function of the hospital was to allow the poor to “learn to live a life of dignity” (Geremek, 1994, p.222). The hospital was also a privilege, as only residents of Paris were eligible to receive its charity. The program of “treatment” that this hospital offered was religious instruction and work – every resident capable of working did so, or faced expulsion. This enforced labour aspect did not, in the eyes of the better-off public, contradict the charity function of the institution, because in no way did the labour of the “imprisoned poor” bring the hospital any profit; it was purely for the dignity it bestowed, the morals it instilled and the respect it gave them for honest work (Geremek, 1994). But not everyone felt the hospitals were such benevolent institutions, especially those who found themselves inside, or likely to be inside them. The next section will deal with these negative perceptions of the hospital as a place of confinement, isolation and punishment – the hospital as a prison.
Hospitals as places of imprisonment
The role of hospitals as a place for keeping people who are seen as a nuisance at large in public has quite a long history. In the middle ages, hospitals were sometimes used by the upper-class in growing trading towns as a place to keep beggars overnight and ensure the peace was kept (Granshaw, 1994). Even recently, the idea of hospitals being a place to “put away” certain groups has surfaced in the public consciousness. During the inter-war period in Britain institutions for the sub-normal, formerly known as “colonies”, started to be called “hospitals” and were established in more remote areas than most mental institutions (ed. Poynter, 1964). Although the establishment of mental hospitals through the 18th and 19th centuries was not based so much in rural or remote areas, their function was still, from the point of view of the public and the patients, the removal from society and imprisonment of dangerous lunatics. It was not until after 1800, when the medical profession started to take an interest in mental disease, that the isolation aspect was thought to be a useful part of treatment (Porter, 1994).
The immediate predecessor of the General Hospital of Paris was the “Hospital for the Imprisoned Poor”, created in 1611 (Geremek, 1994, p.221). Giving alms and begging were both made criminal offences, the former punished by a fine and the latter by being sent to the Hospital. The General Hospital was created in 1656 and absorbed many existing foundations under its auspices (Geremek, 1994, p.223). In a sense it was the first in a series of punishments – expulsion from the hospital or repeated convictions for begging landed vagrants in prisons like other criminals. The lower classes of Paris saw the hospitals as part of the general repression of the poor by the authorities. As part of the program of enforced labour, inmates of the hospital could be hired by outside ventures such as builders. In return for their labour the inmates would receive a fraction of their pay, the rest going to the hospital (Geremek, 1994, p.222, 225). This antagonised the working class – in addition to the high unemployment rate, the hospitals were seen to be making their position seem ever more precarious with the unfair competition they offered for their jobs. The activities of the hospital made it ever more likely that they would end up there themselves (Geremek, 1994, p.226-227). By the 18th century, however, the higher classes too were starting to see the hospital less as a benevolent charitable institution and demanded humanitarian reform. A new institution called a dépôt de mendicité had been created in other parts of France for the imprisonment of professional beggars and the General Hospital was accused of being no better than these establishments (Geremek, 1994, p.228). The hospital still continued to function as a prison, however, for those convicted of begging, while for the unemployed it functioned as a sort of employment office where work was found for them on public projects. Eventually the prison function of the General Hospital was taken over by actual detention centres (Geremek, 1994, p.228).
Hospitals as places of religion
Although as time went on, hospitals began less and less to resemble churches and municipal authorities took over the administrations of many institutions, hospitals continued to perform some of the functions of churches and be established and run by religious groups until relatively recently. Even though it only admitted the sick, he Hôtel Dieu's main function was religious. The Catholic church saw the saving of souls, repentance and forgiveness of sins as the primary function of the hospitals it established and ran. For the Hospitallers and hospitals established according to their code, a sick person could be seen as Christ and therefore the hospital as a monastery (Risse, 1999). The Hôtel Dieu's administration kept records of conversions but non-Catholic babies didn't appear on either the birth or death registers of the 18th century (Richmond, 1961). Joerger (1980) explains that hospitals were a significant part of the Catholic reconquest of France; because they were the ultimate form of charity and the most obvious demonstration of the Catholic belief in salvation through deeds, a much higher ratio of hospitals to population was usually found in Protestant regions. From this we can reasonably extrapolate that, for the Catholic church, one of the main functions of a hospital was to inspire an awe in the public that would create conversions and save souls, as well as attend to the pastoral needs of the patients within the hospital.
One of the significant groups of hospital founders in the newly-explored American west during the 19th century were religious orders, mostly Catholic nursing nuns. These nursing sisters established hospitals for religious reasons and their hospitals performed religious functions – it brought them close to the working migrant population who were predominantly Catholic and put them in a position to impress and possibly convert Protestants (Nelson, 2001). Especially in such a harsh environment as the frontier, hospitals were places to carry out good works of the spirit as well as the body. Missionary work could be a deciding factor as to whether a nursing order would take up a hospital contract (Nelson, 2001, p.104). On the east coast, Catholic nursing orders were often the only nurses brave enough to help during epidemics. As well as being moved to help the suffering, another strong religious motivation for them was to return souls to God – many of the worst affected were migrant Irish living in the poorest slums (Nelson, 2001, p.40). For the nuns, physical care sprang from a spiritual call that for them permeated all their hospital work. For a patient to die without grace was a failure on their part (Nelson, 2001). The Daughters of Charity, the order established by Vincent de Paul and Louise de Marillac, saw themselves as working with God every day because the poor and needy were representatives of Christ (Daniel-Rops, 1961).
Conclusion
As we have seen, the perceived functions of hospitals varied enormously throughout history, depending on whether the person was a patron or a patient, whether they were likely to ever end up in the hospital, or the perception of the people who went into hospitals. The lofty ideals of hospital founders, from the private philanthropists who funded 18th century voluntary hospitals to the authorities and upper-class of Paris at the time of the Hospital for the Imprisoned Poor, were often very differently interpreted by the people who were the beneficiaries of their works. From churches to charities, places of conversion to prisons, bad for ones health or good for it, only recently has the hospital become widely accepted to be the place of medical technology and expertise we know it today. Despite this fundamental shift in perception of the ideal role of the hospital, the perception that it can still be bad for your health persists, as it has done for at least the last 300 years.
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